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1. Please indicate which of the following types of gambling you have done in your lifetime. For each type, mark one answer: "Not at All," "Less than Once a Week," or "Once a Week or More."

Please choose one answer for each statement:

Not At All

Less Than Once a Week

Once a Week or More

a. Played cards for money

b. Bet on horses, dogs, or other animals (at OTB, the track or with a bookie)

c. Bet on sport (parlay cards, with bookie at Jai Alai)

d. Played dice games, including craps, over and under or other dice games

e. Went to casinos (legal or otherwise)

f. Played the numbers or bet on lotteries

g. Played bingo

h. Played the stock and/or commodities market

i. Played slot machines, poker machines, or other gambling machines

j. Bowled, shot pool, played golf, or some other game of skill for money

k. Played pull tabs or "paper" games other than lotteries

(optional question)l. Some form of gambling not listed above Please specify:

2. What is the largest amount of money you have ever gambled with on any one-day?

Never gambled

More than $100 up to $1,000

$1.00 or less

More than $1,000 up to $10,000

More than $1.00 up to $10.00

More than $10,000

More than $10.00 up to $100.00

3. Check which of the following people in your life has (or had) a gambling problem.

Father

Mother

Brother/Sister

Spouse/Partner

Child(ren)

Another Relative

A Friend or Someone Important in My Life

4. When you gamble, how often do you go back another day to win back money you have lost?

Never

Most of the Time

Some of the Time(less than half the time I lose)

Every Time I Lose

5. Have you ever claimed to be winning money gambling, but weren't really? In fact, you lost?

Never

Yes, less than half the time I lost

Yes, most of the time

6.Do you feel you have ever had a problem with betting or money gambling?

No

Yes

Yes, in the past, but not now

7.

Did you ever gamble more than you intended to?

Yes

No

8.

Have people criticized your betting or told you that you had a problem, regardless of whether or not you thought it was true?

Yes

No

9.

Have you ever felt guilty about the way you gamble, or what happens when you gamble?

Yes

No

10.

Have you ever felt like you would like to stop betting money on gambling, but didn't think you could?

Yes

No

11.

Have you ever hidden betting slips, lottery tickets, gambling money, IOUs, or other signs of betting or gambling from your spouse, children or other important people in your life?

Yes

No

12.

Have you ever argued with people you live with over how you handle money?

Have you ever borrowed from someone and not paid them back as a result of your gambling?

Yes

No

15.

Have you ever lost time from work (or school) due to betting money or gambling?

Yes

No

16.

If you borrowed money to gamble or to pay gambling debts, who or where did you borrow from (check "Yes" or "No" for each):

a. From household money

Yes

No

b. From your spouse

Yes

No

c. From other relatives or in-laws

Yes

No

d. From banks, loan companies, or credit unions

Yes

No

e. From credit cards

Yes

No

f. From loan sharks

Yes

No

g. You cashed in stocks, bonds or other securities

Yes

No

h. You sold personal or family property

Yes

No

i. You borrowed on your checking accounts (passed bad checks)

Yes

No

j. You have (had) a credit line with a bookie

Yes

No

k. You have (had) a credit line with casino

Yes

No

Note: By pressing the "Calculate My Score" button, you are not submitting any information from this page to JLAP or any other organization. This form is strictly for informational purposes and your convenience only; no data is being collected. If you would prefer to print this assessment and calculate your score on paper, please open our printer-friendly Adobe PDF version.

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